Healthcare Provider Details

I. General information

NPI: 1306379052
Provider Name (Legal Business Name): CHRISTOPHER J BULLARD MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2017
Last Update Date: 07/19/2024
Certification Date: 07/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

719 S MAIN ST
MOSCOW ID
83843-3041
US

IV. Provider business mailing address

PO BOX 8007
MOSCOW ID
83843-0507
US

V. Phone/Fax

Practice location:
  • Phone: 208-883-1152
  • Fax: 208-882-1486
Mailing address:
  • Phone: 208-882-4511
  • Fax: 208-883-1853

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberM-15235
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: